Disabled Minor Children

1. How does an ALJ evaluate a child claimant’s symptoms?

In considering a claimant’s symptoms, the ALJ must follow a two-step process in which it must first be determined whether there is an underlying medically determinable physical or mental impairment(s)—i.e., an impairment(s) that can be shown by medically acceptable clinical and laboratory diagnostic techniques—that could reasonably be expected to produce the claimant’s pain or other symptoms.

Second, once an underlying physical or mental impairment(s) that could reasonably be expected to produce the claimant’s pain or other symptoms has been shown, the ALJ must evaluate the intensity, persistence, and limiting effects of the claimant’s symptoms to determine the extent to which they limit the claimant’s ability to do basic work activities. For this purpose, whenever statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence, the ALJ must make a finding on the credibility of the statements based on a consideration of the entire case record.

For example, after considering the evidence of record, the ALJ finds that a claimant’s medically determinable impairments could reasonably be expected to produce the alleged symptoms; however, the statements concerning the intensity, persistence and limiting effects of the claimant’s symptoms are no credible to the extent that they are inconsistent with finding that the claimant does not have an impairment or combination of impairments that functionally equals a listing.

For example, if a child were able to attend school in a regular classroom setting and is described as an average student and was participating in physical education and the evidence does not document any restrictions placed on the claimant’s ability to function by any treating or examining physician of record, in terms of the six domains of function the ALJ would probably find the limitations caused by the claimant’s impairments to be minimal.

1a. How can a minor be considered medically disabled?

A minor may have a “disability” but still may not be disabled. Under section 1614(a)(3)(C) of the Social Security Act, an individual under the age of 18 shall be considered disabled if she has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. Notwithstanding the above, no individual under the age of 18 who engages in substantial gainful activity may be considered to be disabled.

1b. Are a disabled child’s SSI benefits payable prior to the date his or her application is filed?

Supplemental security income is not payable prior to the month following the month in which the application was filed (20 CFR 416.335).

1c. Under what authority can an ALJ find a child disabled?

Under the authority of the Social Security Act, the Social Security Administration has established a three-step sequential evaluation process to determine whether an individual under the age of 18 is disabled (20 CFR 416.924(a)).

1d. What are the steps of analyses involved in determining whether a child is disabled?

At step one, the ALJ must determine whether the claimant (child or adult child) is engaging in substantial gainful activity. Substantial gainful activity is defined as work activity that is both substantial and gainful. An individual is engaging in substantial gainful activity is she is doing significant physical or mental activities for pay or profit (20 CFR 416.972). Generally, if an individual has earnings from employment or self-employment above a specific level set out in the regulations, it is presumed that he/she has demonstrated the ability to engage in substantial gainful activity (20 CFR 416.974 and 416.975). If the claimant is performing substantial gainful work, he/she is not disabled regardless of his/her medical condition(s) (20 CFR 416.924(b)). If the claimant is not engaging in substantial gainful activity, the analysis proceeds to the second step.

1e. What is step two in determining whether a child is disabled?

At step two, the ALJ must determine whether the claimant has a medically determinable “severe” impairment or a combination of impairments that is “severe.” For an individual who has not attained age 18, a medically determinable impairment or combination of impairments is not severe if it is a slight abnormality or a combination of slight abnormalities that causes no more than minimal functional limitations. If the claimant does not have a medically determinable severe impairment(s), he/she is not disabled (20 CFR 416.924I). If the claimant has a severe impairment(s), the analysis proceeds to the third step.

1f. What does step three entail?

At step three, the ALJ must determine whether the claimant has an impairment or combination of impairments that meets or medically equals the criteria of a listing, or that functionally equals the listings

1g. What must the ALJ consider?

In making this determination, the ALJ must consider the combined effect of all medically determinable impairments, even those that are not severe (20 CFR 416.923, 416.924a(b)(4), and 416.926a(a) and (c)). If the claimant has an impairment or combination of impairments that meets, medically equals or functionally equals the listings and has lasted or is expected to last for a continuous period of at least 12 months, he/she is presumed to be disabled. If not, the claimant is not disabled (20 CFR 416.924(d)).

1h. What is the purpose of determining the “Six Domains” and functionally equaling a listing?

In determining whether an impairment or combination of impairments functionally equals the listings, the ALJ must assess the claimant’s functioning in terms of six domains: (1) acquiring and using information; (2) attending and completing tasks; (3) interacting and relating with others; (4) moving about and manipulating objects; (5) caring for his or herself; and (6) health and physical well-being.

1i. What does an ALJ have to do to make this assessment?

In making this assessment, the ALJ must compare how appropriately, effectively and independently the claimant performs activities compared to the performance of other children of the same age who do not have impairments. To functionally equal the listings, the claimant’s impairment or combination of impairments must result in “marked” limitations in two domains of functioning or an “extreme” limitation in one domain (20 CFR 416.926a(d)).

1j. What else does an ALJ have to consider?

In assessing whether the claimant has “marked” or “extreme” limitations, the ALJ must consider the functional limitations from all medically determinable impairments, including any impairments that are not severe (20 CFR 416.926a(a)). The ALJ must consider the interactive and cumulative effects of the claimant’s impairment or multiple impairments in any affected domain (20 CFR 416.926a(c)).

1k. What do you mean by a child’s “marked” limitation?

Social Security regulation 20 CFR 416.926a(e)(2) explains that a child has a “marked limitation” in a domain when her impairment(s) “interferes seriously” with the ability to independently initiate, sustain, or complete activities. A child’s day-to-day functioning may be seriously limited when the impairment(s) limits only one activity or when the interactive and cumulative effects of the impairment(s) limit several activities. The regulations also explain that a “marked” limitation also means:

A limitation that is “more than moderate” but “less than extreme.”

The equivalent of functioning that would be expected on standardized testing with scores that are at least two, but less than three, standard deviations below the mean.

A valid score that is two standard deviations or more below the mean, but less than three standard deviations, on a comprehensive standardized test designed to measure ability or functioning in that domain, and his/her day-to-day functioning in domain-related activities is consistent with that score.

For the domain of health and physical well-being, frequent episodes of illnesses because of the impairment(s) or frequent exacerbations of the impairment(s) that results in significant, documented symptoms or signs that occur: (a) on an average of 3 times a year, or once every 4 months, each lasting 2 weeks or more; (b) more often than 3 times a year or once every 4 months, but not lasting for 2 weeks; or (c) less often than an average of 3 times a year or once every 4 months but lasting longer than 2 weeks, if the overall effect (based on the length of the episode(s) or its frequency) is equivalent in severity.

2. What is an “extreme” limitation?

Social Security regulation 20 CFR 416.926a(e)(3) explains that a child has an “extreme” limitation in a domain when her impairment(s) interferes “very seriously” with her ability to independently initiate, sustain, or complete activities. A child’s day-to-day functioning may be very seriously limited when her impairment(s) limits only one activity or when the interactive and cumulative effects of her impairment(s) limit several activities. The regulations also explain that an “extreme” limitation also means:

A limitation that is “more than marked.”

The equivalent of functioning that would be expected on standardized testing with scores that are at least three standard deviations below the mean.

A valid score that is three standard deviations or more below the mean on a comprehensive standardized test designed to measure ability or functioning in that domain, and her day-to-day functioning in domain-related activities is consistent with that score.

For the domain of health and physical well-being, episodes of illness or exacerbations that result in significant, documented symptoms, or signs substantially in excess of the requirements for showing a “marked” limitation.

2a. What must an ALJ do to determine the degree of limitations in each of the “six functional domains”

In determining the degree of limitation in each of the six functional domains the ALJ has to consider all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 416.929, SSRs 96-4p and 96-7p. The ALJ has to also consider the opinion evidence in accordance with 20 CFR 416.927 and SSRs 96-2p, 96-5, 96-6p and 06-3p.

3. What is the first of the six “functional domains”?

The first domain is “Acquiring and using information.” This domain considers how well a child is able to acquire or learn information and use the information he/she has learned (20 CFR 416.926a(g)).

The regulations provide that a preschooler (i.e., a child age 3 to attainment of age 6) without an impairment should begin to learn and use the skills that will help him/her to read and write and do arithmetic when he/she is older. For example, listening to stories, rhyming words, and matching letters are skills needed for learning to read. Counting, sorting shapes, and building with blocks are skills needed to learn math. Painting, coloring, copying shapes, and using scissors are some of the skills needed in learning to write. Using words to ask questions, give answers, follow directions, describe things, explain what he/she means, and tell stories allows the child to acquire and share knowledge and experience of the world around him/her. All of these are called “readiness skills” and the child should have them by the time he/she beings first grade (20 CFR 416.926a(g)(2)(iii)).

The regulations provide that a school-age child (i.e., a child age 6 to the attainment of age 12) without an impairment should be able to learn to read, write, and do math, and discuss history and science. The child will need to use these skills in academic situations to demonstrate what he/she has learned by reading about various subjects and producing oral and written projects, solving mathematical problems, taking achievement tests, doing group work, and entering into class discussions. The child will also need to use these skills in daily living situations at home and in the community (e.g., reading street signs, telling times, and making change). The child should be able to use increasingly complex language (vocabulary and grammar) to share information and ideas with individuals or groups, by asking questions and expressing his/her own ideas, and by understanding and responding to the opinions of others (20 CFR 416.926a(g)(2)(iv)).

Social Security regulation 20 CFR 416.926a(g)(3) sets forth some examples of limited functioning in this domain that children of different ages might have. The examples do not apply to a child of a particular age; rather, they cover a range of ages and developmental periods. In addition, the examples do not necessarily describe “marked” or “extreme” limitation in the domain. Some examples of difficulty children could have in acquiring and using information are: (i) does not understand words about space, size, or time (e.g., in/under, big/little, morning/night); (ii) cannot rhyme words or the sounds in words; (iii) has difficulty recalling important things learned in school yesterday; (iv) has difficulty solving mathematics questions or computing arithmetic answers; or (v) talks only in short, simple sentences, and has difficulty explaining what he/she means.

If the claimant has no limitation in acquiring and using information, the claimant would normally be in a regular classroom setting with no difficulty shown.

3a. What is the second of the six “functional domains”?

The second domain is “Attending and completing tasks.” This domain considers how well a child is able to focus and maintain attention, and how well she is able to begin, carry through, and finish activities, including the pace at which she performs activities and the ease of changing activities (20 CFR 416.926a(h)).

The regulations provide that a preschooler without an impairment should be able to pay attention when she is spoken to directly, sustain attention to her play and learning activities, and concentrate on activities like putting puzzles together or completing art projects. The child should also be able to focus long enough to do many more things independently, such as gathering clothes and dressing, feeding, or putting away toys. The child should usually be able to wait her turn and to change her activity when a caregiver or teacher says it is time to do something else (20 CFR 416.926a(h)(2)(iii)).

The regulations provide that a school-age child without an impairment should be able to focus her attention in a variety of situations in order to follow directions, remember and organize school materials, and complete classroom and homework assignments. The child should be able to concentrate on details and not make careless mistakes in her work (beyond what would be expected in other children of the same age who do not have impairments). The child should be able to change activities or routines without distraction, and stay on task and in place when appropriate. The child should be able to sustain attention well enough to participate in group sports, read by herself, and complete family chores. The child should also be able to complete a transition task (e.g., be ready for the school bus, change clothes after gym, change classrooms) without extra reminders and accommodation (20 CFR 416.926a(h)(2)(iv)).

Social Security regulation 20 CFR 416.926a(h)(3) sets forth some examples of limited functioning in this domain that children of different ages might have. The examples do not apply to a child of a particular age; rather, they cover a range of ages and developmental periods. In addition, the examples do not necessarily describe “marked” or “extreme” limitation in the domain. Some examples of difficulty children could have in attending and completing tasks are: (i) is easily startled, distracted, or over-reactive to sounds, sights, movements, or touch; (ii) is slow to focus on, or fails to complete, activities of interest (e.g., games or art projects); (iii) repeatedly becomes side-tracked from activities or frequently interrupts others; (iv) is easily frustrated and gives up on tasks, including ones she is capable of completing; or (v) requires extra supervision to remain engaged in an activity.

If the claimant has no limitation in attending and completing tasks, the evidence of record would not show any evidence of deficit.

3b. What is the third of the six “Functional Domains”?

The third domain is “Interacting and relating with others”. This domain considers how well a child is able to initiate and sustain emotional connections with others, develop and use the language of the community, cooperate with others, comply with rules, respond to criticism, and respect and take care of the possessions of others (20 CFR 416.926a(i)).

The regulations provide that a preschooler without an impairment should be able to socialize with children as well as adults. The child should begin to prefer playmates and start developing friendships with children who are her own age. The child should be able to use words instead of actions to express herself, and also be better able to share, show affection, and offer to help. The child should be able to relate to caregivers with increasing independence, choose her own friends, and play cooperatively with other children, one-at-a-time or in a group, without continual adult supervision. The child should be able to initiate and participate in conversations, using increasingly complex vocabulary and grammar, and speaking clearly enough that both familiar and unfamiliar listeners can understand what she says most of the time (20CFR 416.926a(i)(2)(iii)).

The regulations provide that a school-age child without an impairment should be developing more lasting friendships with children who are of the same age. The child should begin to understand how to work in groups to create projects and solve problems. The child should have an increasing ability to understand another’s point of view and to tolerate differences. The child should be well able to talk to people of all ages, to share ideas, tell stories, and to speak in a manner that both familiar and unfamiliar listeners can readily understand (20 CFR 416.926a(i)(2)(iv)).

Social Security regulation 20 CFR 416.926a(i)(3) sets forth some examples of limited functioning in this domain that children of different ages might have. The examples do not apply to a child of a particular age; rather, they cover a range of ages and developmental periods. In addition, the examples do not necessarily describe “marked” or “extreme” limitation in the domain. Some examples of difficulty that children could have in interacting and relating with others are: (i) does not reach out to picked up and held by a caregiver; (ii) has no close friends or all friends are older or younger than the child; (iii) avoids or withdraws from people he knows, or is overly anxious or fearful of meeting new people; (iv) has difficulty playing games or sports with rules; (v) has difficulty communicating with others (e.g., in using verbal and nonverbal skills to express herself, in carrying on a conversation, or in asking others for assistance); or (vi) has difficulty speaking intelligibly or with adequate fluency.

A claimant would have no limitation in interacting and relating with others if the evidence does not show any allegation of or objective evidence of any speech or communication disorder.

3d. What is the fourth of the six “Functional Domains”?

The fourth domain is “Moving about and manipulating objects”. This domain considers how well a child is able to move her body from one place to another and how a child moves and manipulates objects. These are called gross and fine motor skills (20 CFR 416.926a(j)).

The regulations provide that a preschooler without an impairment should be able to walk and run with ease. The child’s gross motor skills should let her climb stairs and playground equipment with little supervision, and let her play more independently (e.g., swing by herself and possibly start learning to ride a tricycle). The child’s fine motor skills should also be developing. The child should be able to complete puzzles easily, string beads, and build with an assortment of blocks. The child should be showing increasing control of crayons, markers, and small pieces in board games, and should be able to cut with scissors independently and manipulate buttons and other fasteners (20 CFR 416.926a(j)(2)(iii)).

The regulations provide that a school-age child without an impairment should have gross motor skills that let her move at an efficient pace at school, home, and throughout the neighborhood. The child’s increasing strength and coordination should expand her ability to enjoy a variety of physical activities, such as running and jumping, and throwing, kicking, catching, and hitting balls in informal play or organized sports. The child’s development of fine motor skills should enable her to do things like use many kitchen and household tools independently, use scissors, and write (20 CFR 416.926a(j)(2)(iv)).

Social Security regulation 20 CFR 416.926a(j)(3) sets forth some examples of limited functioning in this domain that children of different ages might have. The examples do not apply to a child of a particular age; rather, they cover a range of ages and developmental periods. In addition, the examples do not necessarily describe “marked” or “extreme” limitation in the domain. Some examples of difficulty children could have in moving about and manipulating objects are: (i) difficulty with motor activities (e.g., stumbling, unintentionally dropping things) because of muscle weakness, joint stiffness, or sensory loss (e.g., spasticity, hypotonia, neuropathy, or paresthesia); (ii) difficulty with balance or climbing up and down stairs, or jerky or disorganized locomotion; (iii) difficulty coordinating gross motor movements (e.g., bending, kneeling, crawling, running, jumping rope, or riding a bike); (iv) difficulty with sequencing hand or finger movements; (v) difficulty with fine motor movement (e.g., gripping or grasping objects); or (vi) poor eye-hand coordination when using a pencil or scissors.

A claimant has no limitation in moving about and manipulating objects if the examination of the claimant had not shown any neurological or orthopedic deficits, or that a claimant participates in physical education at school and physical education was one of her favorite classes.

3e. What is the fifth of the six “Functional Domains”?

The fifth domain is “caring for yourself”. This domain considers how well a child maintains a healthy emotional and physical state, including how well a child satisfies her physical and emotional wants and needs in appropriate ways. This includes how the child copes with stress and changes in the environment and whether the child takes care of her own health, possessions, and living area (20 CFR 416.926a(k)).

The regulations provide that a preschooler without an impairment should want to take care of many of her own physical needs (e.g., putting on shoes, getting a snack), and also want to try doing some things that she cannot do fully (e.g., tying shoes, climbing on a chair to reach something up high, taking a bath). Early in this age range, it may be easy for the child to agree to do what her caregiver asks. Later, that may be difficult for the child because she wants to do things her way or not at all. These changes usually mean that the child is more confident about her ideas and what she is able to do. The child should also being to understand how to control behaviors that are not good for herself (e.g., crossing the street without an adult) (20 CFR 416.926a(k)(2)(iii)).

The regulations provide that a school-age child without an impairment should be independent in most day-to-day activities (e.g., dressing and bathing), although she may still need to be reminded sometimes to do these routinely. The child should begin to recognize that she is competent in doing some activities but has difficulty doing others. The child should be able to identify those circumstances when she feels good about herself and when she feels bad. The child should begin to develop understand of what is right and wrong, and what is acceptable and unacceptable behavior. The child should also begin to demonstrate consistent control over her behavior, and be able to avoid behaviors that are unsafe or otherwise not good for her. At this age, the child should begin imitating more of the behavior of adults she knows (20 CFR 416.926a(k)(2)(iv)).

Social Security regulation 20 CFR 416.926a(k)(3) sets forth some examples of limited functioning in this domain that children of different ages might have. The examples do not apply to a child of a particular age; rather, they cover a range of ages and developmental periods. In addition, the examples do not necessarily describe “marked” or “extreme” limitation in the domain. Some examples of difficulty children could have in caring for themselves are: 9i) continues to place non-nutritive or inedible objects in the mouth; (ii) often uses self-soothing activities that are developmentally regressive (e.g., thumb-sucking or re-chewing food); (iii) does not dress or bathe age-appropriately; (iv) engages in self-injurious behavior (e.g., suicidal thoughts or actions, self-inflicted injury, or refusal to take medication), or ignores safety rules; (v) does not spontaneously pursue enjoyable activities or interests; or (vi) has disturbances in eating or sleeping patterns.

A claimant would have no limitation in the ability to care for herself if no problems were alleged in this area and no deficits were observed by any treating sources.

3f. What is the last of the six “Functional Domains”?

The sixth domain is “health and physical well-being”. This domain considers the cumulative physical effects of physical and mental impairments and any associated treatments or therapies on a child’s functioning that were not considered in the evaluation of the child’s ability to move about and manipulate objects (20 CFR 416.929a(l)).

Social Security regulation 20 CFR416.926a(l)(3) sets forth some examples of limited functioning in this domain that children of any age might have; however the examples do not necessarily describe “marked” or “extreme” limitation in the domain. Some examples of difficulty children could have involving their health and physical well-being are: (i) generalized symptoms, such as weakness, dizziness, agitation (e.g., excitability), lethargy (e.g., fatigue or loss of energy or stamina), or psychomotor retardation because of any impairment(s); (ii) somatic complaints related to an impairment (e.g., seizure or convulsive activity, headaches, incontinence, recurrent infections, allergies, changes in weight or eating habits, stomach discomfort, nausea, headaches or insomnia); (iii) limitations in physical functioning because of treatment (e.g., chemotherapy, multiple surgeries, chelation, pulmonary cleansing, or nebulizer treatments); (iv) exacerbations from an impairment(s) that interfere with physical functioning; or (v) medical fragility requiring intensive medical care to maintain level of health and physical well-being.

If a claimant has no marked limitation in health and physical well-being, she does not fulfill the domain criteria.

3g. If a child has only one “marked” limitation and no “severe” ones, can she be found to be disabled?

No. The requirement of severity is not met by equaling or surpassing only one “severe” limitation. Accordingly, if a claimant does not have any impairment or combination of impairments that result in either “marked” limitations in two domains of functioning or “extreme” limitation in one domain of functioning.

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